"Medicine is a social science, and politics is nothing else but medicine on a large scale"—Rudolf Virchow

May 25, 2019

After serious setbacks in April led to a cluster of new polio cases, Pakistan is revamping its vaccination strategy in a renewed effort to wipe out the virus.

The country is one of just three — along with Afghanistan and perhaps Nigeria — in which polio is still endemic. Eradication of the virus in Pakistan is crucial to the drive to rid the world of polio, once and for all.

Now, vaccination teams will take a friendlier approach, ask fewer questions, make fewer follow-up visits, and stop recording extensive details about the families they visit, Pakistan’s polio eradication program announced.

Families were intimidated by the questions, and vaccinators spent too much time filling out the registration forms introduced in 2016, said Babar Atta, the polio coordinator in the prime minister’s office, according to local media.

A new vaccination drive is scheduled for the second week of June; thousands of teams will spread out around the country trying to reach almost 40 million children under age 10.

Many vaccinators will go house to house, while others will look for families with young children in refugee camps, train and bus stations, and at highway checkpoints.

Pakistan has had 17 cases of polio paralysis this year; it had only three by this date last year, and only 12 in all of 2018.

In mid-April, widespread panic among parents in Peshawar and the surrounding northern tribal areas forced the suspension of a national immunization drive.

A scaremongering video spread on Twitter, purporting to show students collapsing after getting an expired batch of vaccine.

The video seemed obviously fake. The boys in it flop prone across a hospital bed on cue after the speaker waves his hand; one even makes a funny face on camera. Also, expired vaccine — if it was expired — is harmless.

Nonetheless, “our TV channels found it profitable to cover this nonsense,” Aziz Memon, a textile executive who leads Rotary International’s involvement in Pakistan’s anti-polio campaign, said in an interview in New York. “It became a national event.”

Rumors spread that 50 children had died; mosques used their loudspeakers to tell parents to rush their children to medical care. Hospitals were swamped as more than 25,000 children arrived.

“No one had died,” Mr. Memon said. “But we had to call everything off.”

Local politics were behind the scare, he said. District elections were underway and the conservative Jamaat-e-Islami party was trying to discredit the polio campaign, which is supported by Prime Minister Imran Khan’s Tehreek-e-Insaf party.

The man speaking in the video was arrested.

To restore confidence, Mr. Memon added, the district health and communications ministers appeared on television giving vaccine drops to their own children.

Because suspicion of the campaign remains high in some areas — vaccinators have been accused of marking targets for American drones — interactions with families will now be briefer and less intrusive.

Almost every week our newspapers report new studies on the damage that air pollution does to our health and especially to children. For example, last November, researchers revealed reduced lung growth in children who lived in the most polluted parts of east London.

In March 2018, a group of Belgian parents took action. Instead of going for coffee on a Friday morning, they closed the road outside their children’s school. They named their movement Filter-Café-Filtre. Over the next two weeks, another 42 schools joined in. Now parents and teachers in 21 cities meet each Friday morning. With hazard tape from DIY shops, banners and musical instruments, they close about 76 schools. Children play in the street and the parents drink coffee together to demand traffic-free zones, better walking and cycling routes and public transport so children do not have to be driven to school.

A survey by Sustrans found that nearly two-thirds of UK teachers wanted roads closed around their schools. Starting in Italy and then Scotland, so-called School Streets are spreading fast. About 20 UK schools now have traffic-free zones at drop-off and pickup times to reduce road accidents, reduce air pollution exposure and encourage walking and cycling to school.

No WPV cases have been detected in Nigeria since 2016. WPV transmission has continued in Afghanistan and Pakistan in all previously identified reservoirs. The number and extent of cVDPV outbreaks increased in 2018. Countries with endemic polio have revised emergency action plans to innovate and intensify strategies to reach and vaccinate every child in underimmunized populations.

What are the implications for public health practice?

Successful implementation of locally relevant strategies in all areas will be essential to interrupting WPV transmission.

Many doctors and nurses working in the territories of Beni and Lubero are forced to flee, move or temporarily leave their homes following death threats.

It is the Ministry of Health which announces it in its last communiqué dedicated to the epidemic. Particularly affected, the staff of the health zone of Musienene in Lubero where, serious consequence, several health centers were simply forced to close.

Verbal threats, phone calls or leaflets calling for violence against them, doctors and nurses of Lubero live in a climate of "anguish", according to the president of the civil society of the territory. In Musienene, for example, at least three health centers have already closed after their staff had to flee urgently.

Armed groups

This Thursday, during a meeting, the nurses of this health zone all threatened to go on strike if the authorities do not take the necessary steps quickly to stop these threats. "We do not know the exact origin of the threats," says George Kasongo, the president of the local civil society, but in some leaflets, reference is made to armed groups, many in the area, hence the growing concern.

These health center closures not only impact the spread of Ebola but also the entire health system. In Musienene, a pregnant woman sometimes has to travel up to 40 kilometers of road in very bad condition to find care without forgetting malaria, a disease for which some of the inhabitants has already deserted the health centers, sometimes fearing an attack, but most often to be suspected of having contracted Ebola and driven to one of the treatment centers of the epidemic, perceived as dying by part of the population.

The MoH/WHO AFRO Ebola DRC KIVU 2018 Dashboard reports 9 new cases on May 24, making the weekly total 71 and the outbreak total 1,903. The number of probable cases is 94, up 6 from yesterday, and presumably reflecting fatal cases unsafely buried without being tested.

May 24, 2019

MSF remains an active player in the Ebola response. Following separate attacks on our Ebola Treatment Centers (ETCs) in Butembo and Katwa—at the epicenter of the outbreak—earlier this year, MSF is not currently running treatment centers. MSF is helping existing health care structures in North Kivu and Ituri provinces to prepare for and handle potential Ebola cases and managing transit centers where patients with suspected Ebola are tested and sent to ETCs if they test positive.

Additionally, the organization is involved in prevention activities by working to implement and strengthen disease surveillance and infection prevention and control activities (IPC) in the region, as well as working with local structures to make sure they have the capacity and equipment to isolate possible positive cases.

Working closely with communities to identify and address their specific needs is critical. In addition to Ebola activities, MSF is helping to increase access to general health care to treat other common illnesses and improve water and sanitation to prevent the spread of waterborne diseases. Increasing access to basic health care can help reduce the number of new cases of Ebola. It is safer to keep people out of hospitals, where they could come into contact with others who are infected with the virus.

Local context

The epicenter of the outbreak is in North Kivu province, a densely populated area in the country’s northeast with approximately seven million people. Despite the challenges of rough terrain and bad roads, the population is highly mobile. North Kivu shares a border with Uganda to the east and sees a lot of trade, as well as human trafficking and “irregular” crossings. Some communities live on both sides of the border and cross back and forth frequently to visit relatives or trade goods.

North Kivu has been an area of conflict for over 25 years, with more than 100 armed groups estimated to be active. Criminal activity, such as kidnappings, are relatively common, and skirmishes between armed groups occur regularly. Widespread violence has uprooted people and made some areas in the region quite difficult to access. While most of the urban areas are relatively less exposed to the conflict, attacks and explosions have taken place in Beni, a regional administrative center, sometimes limiting MSF’s ability to run operations.

The current epidemic was first declared in the small town of Mangina, and the outbreak’s epicenter has appeared to move toward the south, first to the city of Beni, and later to the larger city of Butembo, a trading hub. Nearby Katwa became a new hotspot near the end of 2018, and cases have been found further south. Meanwhile, sporadic cases have also appeared in neighboring Ituri province to the north.

Community challenges

All actors involved in the Ebola response have failed to build trust within the local community. Widespread mistrust, as well as violent attacks against the Ebola response, are hampering the efforts to control the epidemic. People are not seeking care in Ebola Treatment Centers. This has resulted in an increased likelihood that the virus could spread in other health facilities that aren’t equipped with proper infection control procedures and equipment.

About half of all the new cases are community deaths, which means people are either dying at home or in general health care facilities. This is an indication of the persistent lack of trust in the intervention. People dying of Ebola in the community also present a significant risk of transmission to others.

Additionally, violence and unrest—such as fighting between the army and armed groups in early May, and the killing of a World Health Organization doctor in April in Butembo—have brought many activities to a standstill. For instance, vaccination of contacts, contacts of contacts, and frontline workers in Butembo and Katwa, is sometimes temporarily suspended because of threats to the safety of vaccination teams.

It will not be possible to end this outbreak if there is no trust built between the Ebola response and the affected people. We have to listen to the needs of communities, restore their choice when it comes to managing their health, and involve them in every aspect of the Ebola response.

Epidemiological concerns

Overall, the geographic spread of the epidemic appears to be unpredictable, with diffuse small clusters of cases potentially occurring anywhere in the region. This pattern makes ending the outbreak even more challenging. Given the appearance of new confirmed cases further to the south, the risk of the epidemic reaching Goma, the capital of the province, is another reason for concern.

MSF is extremely worried about the lack of visibility on the actual epidemiological situation as more than 80 percent of new confirmed cases have not been identified as contacts. Additionally, as few as 32 percent of the new confirmed cases were linked back to known contacts.

This means that the listing of contacts and surveillance are not effective. Contact tracing is essential to control the evolution of the outbreak. This also mean that while the number of new cases being reported is high, the real number is likely to be even higher.

(Kinshasa, May 24, 2019) - The case concerning the assassination of the WHO doctor, Dr. Richard Muzoko of Cameroon nationality will be quickly fixed before the operational military court of North Kivu as early as next week. Information confirmed by the Military Advocate General in North Kivu, Lieutenant Colonel Jean Baptiste Kumbu Ngoma.

The senior military court has already recovered some property including cell phones looted during the Maimai militia incursion at university clinics of the Graben Catholic University "UCG" and at the Katwa Reference General Hospital in the commercial city of Butembo last April 14th.

The Advocate General states that the file will be split in two. First, for those who attacked Katwa and then those of the UCG.

According to the same source, the assassination was planned by Kakule Sengesenge, head of the Office of Culture and Arts in Kimemi commune in the same city. The aforementioned would already be at the stops.

Lieutenant Colonel Jean Baptiste Kumbu Ngoma asserts that Kakule Arsene Dominique aka Rainbow Patient, Militia leader Ndeke, Alba and Fombuma also allegedly took part in this planning meeting for the assassination of the WHO doctor and they have recognized on minutes.

EVOLUTION OF THE EBOLA EPIDEMIC IN THE PROVINCES OF NORTH KIVU AND ITURI

Friday, May 24, 2019

The epidemiological situation of the Ebola Virus Disease dated 23 May 2019:

• Since the beginning of the epidemic, the cumulative number of cases is 1,888, of which 1,800 are confirmed and 88 are probable. In total, there were 1,254 deaths (1,166 confirmed and 88 probable) and 492 people cured.

• 343 suspected cases under investigation;

• 11 new confirmed cases, including 3 in Mabalako, 3 in Katwa, 2 in Butembo, 2 in Mandima and 1 in Kalunguta;

• 6 new confirmed deaths, including:

º 5 community deaths, 2 in Mandima, 1 in Butembo, 1 in Katwa and 1 in Kalunguta;

• 1 death at Katwa CTE;

• 2 new healings from the Katwa CTE.

/! \ The data presented in this table are subject to change later, after extensive investigations and after redistribution of cases and deaths in their health areas.

FIGURES OF THE RESPONSE

123,526 vaccinated persons

831 people vaccinated on 23/05/2019.

• Of those vaccinated, 34,048 are high-risk contacts (CHR), 60,522 are contacts of contacts (CC), and 28,956 are first-line providers (PPL).

• Persons vaccinated by health zone: 32,412 in Katwa, 25,048 in Beni, 15,798 in Butembo, 9,883 in Mabalako, 6,033 in Mandima, 4,379 in Kalunguta, 3,070 in Goma, 3,048 in Komanda, 2,569 in Oicha, 2,035 in Masereka, 1,998 in Lubero , 1,980 to Kayna, 1,935 to Vuhovi, 1,817 to Kyondo, 1,657 to Musienene, 1,487 to Bunia, 1,040 to Biena, 1,012 to Mutwanga, 690 to Rutshuru, 557 to Rwampara (Ituri), 527 to Nyankunde, 496 to Mangurujipa, 494 to Alimbongo, 420 to Mambasa, 355 to Tchomia, 342 to Kirotshe, 333 to Lolwa, 250 to Mweso, 245 to Kibirizi, 161 to Nyiragongo, 97 to Watsa (Haut-Uélé) and 13 to Kisangani.

• The only vaccine to be used in this outbreak is the rVSV-ZEBOV vaccine, manufactured by the pharmaceutical group Merck, following approval by the Ethics Committee in its decision of 19 May 2018.

The Kagadi Ebola Task Force led by the District Surveillance Officer, Mr Selevano Thembo, went to the area to investigate the matter.

Wearing protective clothes, the team carried out the burial as one of the precautionary procedures in cases of suspected contagious diseases.

"When people see blood coming out of their sick relatives, they tend to take it as a serious disease and our team went to investigate," Mr Thembo said.

He said that they got blood samples from the bodies which will be taken to the Uganda Virus Research Institute for analysis.

"Our district is at risk because of the outbreak of the Ebola disease in DR Congo," Mr Thembo said.

Diseases which present with signs and symptoms similar to those of Ebola include Rift Valley Fever-RVF, Crimean Congo Haemorrhagic Fever-CCHF and Marburg fever.

In 2018, Crimean Congo Haemorrhagic Fever outbreak was confirmed in neighbouring Kakumiro District in Nkooko Sub-county. It claimed one person.

In late April, the Ministry of Health gave Shs146 million to Kagadi District for Ebola preparedness activities.

This is not just another health-scare story. The link in the text will take you to a report in 2012 about a real Ebola outbreak in Kagadi, and the town had a similar case less than a month ago. It's also useful to be reminded that Ebola's early symptoms mimic those of several other common diseases in the region—a major reason why relatively few suspected Ebola cases are confirmed.

Health officials in five states have warned people believed to be infected with measles and planning to travel that they could prevent them from getting on planes.

All eight individuals agreed to cancel their flights after learning the officials could ask the federal government to place them on a Do Not Board List managed by the Centers for Disease Control and Prevention, said Martin Cetron, director of the agency’s Division of Global Migration and Quarantine, which tracks disease outbreaks.

“The deterrent effect is huge,” he said.

CDC officials said the agency had been contacted about the individuals by health officials in New York, California, Illinois, Oklahoma and Washington.

The government’s travel ban authority often gets little discussion “because it is a politically charged and politically visible request,” said Lawrence Gostin, a professor of global health policy at Georgetown University.

Though less restrictive than isolation or quarantine, the public health measure “is seen as a government using its power over the people and the states, which is kind of toxic in America right now,” said Gostin. “There is nothing unethical or wrong about it. It’s just plain common sense that if you have an actively infectious individual, they should not get on an airplane.”

Health officials emphasize that vaccination is the best and most effective way to protect against measles, and that the majority of people with infectious, communicable diseases, like measles, listen to doctors’ advice not to travel.

Officials in Rockland County, N.Y. and New York City, the epicenter of measles outbreaks since last fall, say they have advised several infected individuals against traveling.

Earlier this spring, Rockland health officials, who have had 238 measles cases since last October, consulted with CDC about placing two infectious individuals on the list to prevent them from flying to Israel for the Passover holiday, a county spokesman said.

“It served as an effective deterrent,” said spokesman John Lyon. “They did not travel."

Nine months into the second largest Ebola outbreak the world has ever seen—the tenth to hit the Democratic Republic of Congo—and the data are brutally clear: whatever we, Ebola responders, have been doing so far has not been working. The Ebola response in North Kivu and Ituri, the two provinces in the DRC currently affected by the epidemic, is failing. Almost every day seems to bring a new record number of cases—many of which end in deaths in the community—and the overall mortality rate remains well over 60%.

It was not supposed to be this way. After the 2014 west Africa Ebola outbreak there was a determination that such a catastrophe should not be allowed to happen again. UN agencies restructured their emergency response teams, research teams plowed millions of dollars into new pharmaceuticals, and academic journals were full of new insights and understandings into this previously poorly understood disease.

When the first cases of this outbreak were reported in August 2018, the Congolese government, WHO, the World Bank, and international medical organisations (including MSF) responded quickly, armed with strong financial support, a promising vaccine, new experimental treatments, and a far deeper understanding of Ebola than in 2014.

Despite this, the response has failed. In the volatile context of North Kivu—a region where armed groups, distrust of government, and socioeconomic injustices violently intersect—the Ebola response has been met with distrust and violent attacks on health workers and health facilities, the most recent being the killing of Dr Richard Mouzoko.

The social and political dynamics at play in North Kivu are complex, and there is no magic bullet to this crisis. It’s clear that the local community has lost what little trust it had in the ability of national and international organisations to respond to the epidemic, but what’s less evident is the next steps we can take to solve this problem. Based on our experience of working in North Kivu, these are some concrete suggestions of where we could go next.

Normalising Ebola

Of all the suspect cases admitted to Ebola centres, only a small minority (less than 10%) of patients end up having the disease, which reinforces the idea that Ebola is not real. Integrating Ebola into the regular system of care would help overturn this perception that these Ebola centres are part of a wider conspiracy against the population. Decentralising the isolation and testing of suspect patients and allowing them to remain at a facility they trust in their community would go a long way in increasing acceptance of the disease.

However, this can only be successful if we simultaneously re-institute sound triage practices, which isolate and test only those patients who respond to the standardised Ebola case definition. This would ensure that health centres (or Ebola centres) wouldn’t unnecessarily be overwhelmed with false suspect cases held for three days awaiting their results—at risk of getting Ebola, and at risk of not getting the care they need.

Improving access to diagnostics

One of the frustrating aspects of working in this epidemic has been the limited access to diagnostics. One of the most significant developments during the 2014 outbreak was the use of GeneXpert machines to improve the turnaround time of tests, but the full potential of this technology has not been reached during this outbreak. The complete oversight of laboratory results by the government, as well as the limited hours of operation of laboratories, has meant unnecessarily long waits for lab results. Delays in sample transportation has meant that patients (or the families of deceased persons) were often kept waiting overnight for a result that should have been available within four hours.

Humanising Ebola

One of the characteristics of this epidemic has been the aggressive attitude to finding new suspect cases. There have been reports of patients being forced into Ebola centres by the authorities. This is not only an affront to basic ethical principles, but it is also utterly counterproductive as it promotes anger and distrust amongst the communities we need to partner with.

Although some people in the affected areas still suggest that Ebola is not ‘real’, most do not question its existence but ask why it continues to spread. People see themselves as ‘doing their part’ to contain Ebola – washing their hands, agreeing to culturally sensitive but medically safe burials – and now question the motives of response teams.

They view the significant financial and technical resources mobilised around Ebola as being at odds with the progress of the response. Some question whether financial interests and political agendas dampen the response’s commitment to ending the outbreak, and frustrations are expressed when response teams attribute the spread of the outbreak to a lack of community buy-in.

In the context of North Kivu, ownership must go beyond conventional understandings of ‘community’: the population is highly fragmented, with shifting allegiances to a range of state and local authorities and non-state actors. People in the affected areas repeatedly emphasise the need to avoid empowering certain individuals or population groups at the expense of others, and to build trust across the numerous different population factions, particularly by adjusting response activities in light of local feedback.

Critical roles for socio-cultural knowledge

The Social Science in Humanitarian Action Platform, a partnership between the Institute of Development Studies and Anthrologica with support from UNICEF, the Wellcome Trust, DFID and others, is mobilising networks of anthropologists, social scientists, and DRC experts to provide sociocultural and local context analysis that can be used in the design of effective and appropriate strategies to tackle the outbreak.

By understanding the origins of violent attacks against health workers and distrust in state authorities and international agencies, responders are better placed to develop strategies to mitigate these risks. By understanding where, how, and from whom different social groups seek healthcare, the everyday social, economic, political, and livelihood interactions that are significant to different people, and who they turn to for advice and reassurance, the on-the-ground realities of ‘communities’ come into view, informing a more inclusive response.

Listening to communities

Across the response, an enhanced strategy of community engagement must deliver on repeated local requests for more in-depth knowledge about Ebola, the response, and treatment procedures. Local actors continue to affirm that improved information flows can de-escalate more politicised views of Ebola. Communities suggest more (facilitated discussion) forums in which they can ask questions and receive further detailed information about the virus, its treatment, vaccination, and response activities.

Actors both opposing the response as well as those supporting it call for greater civilian access to laboratories and treatment centres in order to build familiarity with procedures used. Given the environment of distrust, granting more direct access will help to overcome ‘fear of the unknown’ and can constructively dispel misinformation.

Although the recent attacks are highly visible, communities continue to make repeated attempts to communicate peacefully with the government and national and international responders. Community members circulate announcements and situation reports from the WHO and other agencies via WhatsApp, demonstrating a determination to keep apprised of response activities. This level of engagement is positive and should be maximised. It should be the basis for the reset.

Adopting a community-centred approach

As suspected Ebola cases continue to go under-reported, people continue to present late at health facilities and treatment units, and those who are untreated continue to die at home, it is only through strengthening community-based surveillance and locally led response actions that the outbreak will be controlled.

A total of four patients or health workers involved in the response to the Ebola haemorrhagic fever outbreak have been killed and 38 others wounded in 132 attacks on medical facilities in the last two months in two eastern provinces of the Democratic Republic of Congo (DRC), said Thursday evening the Congolese health authority.

"Between 1 August 2018 and 20 May 2019, 132 attacks against health facilities were recorded as part of the Ebola outbreak, causing 4 deaths and 38 injuries among health workers and patients," says the ministry of health in a statement.

"This violence against health workers must be condemned unreservedly and there must be a clear distinction between community involvement and targeted violence by armed militias," writes the Ministry of Health.

Linking the two is tantamount to "stigmatizing the entire community of affected communities, portraying them as deeply violent communities, and blaming the health workers who are the first victims of this targeted violence," emphasizes the same source.

As of May 22, the outbreak of the North Kivu province before touching Ituri had already killed 1,246 deaths including 1,160 among the 1,789 confirmed cases, according to an official count.

A third of the patients are children, according to the World Health Organization (WHO), whose general director, Dr. Tedros Adhanom, considers the current epidemic of Ebola "public enemy number 1".

On its website, this UN agency maintains that the risk of spread in other provinces in the east of the country as well as in neighboring countries remains "very high".

The biggest challenge for this epidemic is complex: local communities are in denial of disease.

They are suspicious of agents deployed by Kinshasa and WHO to counter the epidemic, which they consider to be a Western invention to exterminate the populations of the region.

This mistrust is fueling local militias that are now attacking health facilities.

This violence has already caused several doctors and nurses from Beni and Lubero (North Kivu) to move or temporarily leave their homes, forcing some health facilities to close their doors.

"This is particularly the case in the Kyondo Health Zone where activities have been suspended at the Kyakumba Health Reference Center since Tuesday, May 21, 2019, since the attending physician and the nurse-in-charge left the feared area for their health. security." says the ministry.

In a statement on Thursday mid-day, nurses in the health zone of Musienene in North Kivu denounced the "death threats and destruction" of health facilities they receive in recent days because of their role in the response to Ebola. They threatened to make a "dry strike" if the threats do not stop.

The current Ebola outbreak is the deadliest recorded on Congolese territory since the discovery of the Ebola Virus in 1976 in the DRC. The country is in its tenth epidemic.

Although this past week continues to bear witness to a steady rise in the number of Ebola virus disease (EVD) cases in the Democratic Republic of the Congo, the overall security situation has allowed for the resumption of most response activities.

While no major insecurity incidents have occurred, outbreak response teams, local healthcare workers, and community members cooperating with response efforts, are increasingly subjected to threats made against them by armed groups present in hotspot areas such as Katwa and Butembo. These threats are often disseminated through leaflets or direct intimidation.

Armed groups’ presence, activities and increasing direct threats against response teams continue to be reported in other EVD affected areas, in particular Lubero, Masereka, Mabalako, Kalunguta, and Vuhovi, resulting in some healthcare workers being unwilling to don personal protective equipment or perform critical Infection Prevention Control (IPC) measures out of fear of violence being levied against them or the healthcare facilities where they operate.

During the past three weeks, reports indicate that transmission remains most intense in seven main hotspot areas: Beni, Butembo, Kalunguta, Katwa, Mabalako, Mandima, and Musienene. Collectively, these health zones account for the vast majority (93%) of the 349 cases reported in the last 21 days between 1 - 21 May 2019 (Figure 1 and Table 1). During this period, new cases were reported from 91 health areas within 15 of the 22 health zones affected to date (Figure 2).

As of 21 May, a total of 1866 confirmed and probable EVD cases have been reported, of which 1241 died (case fatality ratio 67%). Of the total cases with recorded sex and age, 56% (1051) were female and 30% (545) were children aged less than 18 years. The number of healthcare workers affected has risen to 105 (6% of total cases). 490 EVD patients who received care at ETCs have been successfully discharged.

WHO risk assessment

WHO continuously monitors changes to the epidemiological situation and context of the outbreak to ensure that support to the response is adapted to the evolving circumstances. The last assessment concluded that the national and regional risk levels remain very high, while global risk levels remain low.

Weekly increases in the number of new cases has been ongoing since late February 2019. A general deterioration of the security situation, and the persistence of pockets of community mistrust exacerbated by political tensions and insecurity, have resulted in recurrent temporary suspension and delays of case investigation and response activities in affected areas, reducing the overall effectiveness of interventions.

However, recent community dialogue, outreach initiatives, and restoration of access to certain hotspot areas have resulted in some improvements in community acceptance of response activities and case investigation efforts.

The high proportion of community deaths reported among confirmed cases, relatively low proportion of new cases who were known contacts under surveillance, existence of transmission chains linked to nosocomial infection, persistent delays in detection and isolation in ETCs, and challenges in the timely reporting and response to probable cases, are all factors increasing the likelihood of further chains of transmission in affected communities and increasing the risk of geographical spread both within the Democratic Republic of the Congo and to neighbouring countries.

The high rates of population movement occurring from outbreak affected areas to other areas of the Democratic Republic of the Congo and across porous borders to neighbouring countries during periods of heightened insecurity further compounds these risks. Additional risks are posed by the long duration of the current outbreak, fatigue amongst response staff, and ongoing strain on limited resources.

Conversely, substantive operational readiness and preparedness activities in a number of neighbouring countries have likely increased capacity to rapidly detect cases and mitigated local spread. However, these efforts must continue to be scaled-up at this time.

I got into blogging because I was fascinated by the way we read and write on the web, compared with print on paper. One thing I soon learned: we read more slowly online than on paper.

But, as on paper, we read the beginnings and ends of sentences and paragraphs more closely than the middles. We understand short words, sentences, and paragraphs far better than long ones.

I have broken the WHO excerpt into shorter paragraphs. The original WHO risk assessment paragraph is 312 wretched words long. When I ran it through a readability test, it scored "very difficult to read" on two of them and "college graduate" on five of them. Over all, you'd need eight years of grad school to make sense of it.

I broke it into six paragraphs, and it's still almost unreadable. The paragraph beginning "The high proportion" is a single sentence 82 words long. Text on a website gets into trouble if a sentence is more than 10 or 12 words long.

This is why I routinely re-paragraph many WHO and other reports—because they're not written properly for the web. Online readers skim, looking for key information in short paragraphs. They skip long paragraphs and anything buried inside them.

Sure, highly educated health bureaucrats could savour that risk assessment like a rich assortment of dessert pastries, but WHO is supposed to be writing for ordinary people. If such people can't even understand WHO's reports, they won't put any pressure on their governments to do something.

Much of the grief in this Ebola outbreak, WHO itself admits, is due to inept communications with the people actually catching Ebola. Funding to stop the outbreak is running short. The UN's bureaucrats get it, and promise more aid, but their promises are as unreadable as WHO's DONs (disease outbreak news stories).

This is not rocket science. It's not even how-to-ride-a-horse science. When I was a tech writer long ago at the Lawrence Berkeley Lab, I was told to write our annual report in terms that could be understood by a first-term congressperson on the Atomic Energy Committee. I understood, and wrote it as clearly, concisely, simply as I could.

And I didn't dumb it down. As Wolfgang Pauli himself is supposed to have said, "If you can't explain quantum mechanics to an eight-year-old, you don't understand it yourself." Like any teacher, any health communicator should start with the reader or listener. That involves knowing who the reader or listener is, not how smart or educated we are.

As students, we soon size up our teachers' competence; as teachers, we soon forget how smart our students are.

EVOLUTION OF THE EBOLA EPIDEMIC IN THE PROVINCES OF NORTH KIVU AND ITURI

Thursday 23 May 2019

The epidemiological situation of the Ebola Virus Disease dated 22 May 2019:

• Since the beginning of the epidemic, the cumulative number of cases is 1,877, of which 1,789 are confirmed and 88 are probable. In total, there were 1,248 deaths (1,160 confirmed and 88 probable) and 490 people healed.

• 298 suspected cases under investigation;

• 11 new confirmed cases, including 6 in Butembo, 1 in Katwa, 1 in Beni, 1 in Mabalako, 1 in Mandima and 1 in Kalunguta;

• 7 new confirmed deaths, including

º 2 community deaths in Butembo;

º 5 deaths at CTE, including 1 in Mabalako, 1 in Butembo and 3 in Beni.

/! \ The data presented in this table are subject to change later, after extensive investigations and after redistribution of cases and deaths in their health areas.

NEWS

• This Thursday, May 23, 2019, the United Nations has taken a series of measures to strengthen their support for the response to Ebola in the Democratic Republic of Congo. In particular, by strengthening its political commitment and operational support, the United Nations wants to help improve the environment in which the response teams work to facilitate access to affected communities. Click here to read the full press release.

Security situation

• Nurses in the Musienene Health Zone have denounced the death threats and destruction of health facilities they have received in recent days because of their role in the Ebola response. The Musienene nurses held an extraordinary meeting on Thursday, May 23, 2019 to evaluate their working conditions. They asked the politico-administrative authorities to get involved in putting an end to this phenomenon of violence against health workers because, if the threats do not stop, they plan to go on a dry strike.

• Because of this targeted violence, several doctors and nurses in the Beni and Lubero territories had to move or temporarily leave their homes, forcing some health facilities to close their doors. This is particularly the case in the Kyondo Health Zone where activities have been suspended at the Kyakumba Health Reference Center since Tuesday, May 21, 2019, since the attending physician and the nursing staff left the feared zone for their safety.

• Between 1 August 2018 and 20 May 2019, 132 attacks against medical units were recorded as part of the Ebola outbreak, causing four deaths and 38 injuries among health workers and patients. As the Minister of Health, Dr. Oly Ilunga Kalenga, recalled at the 72nd World Health Assembly in Geneva, this violence against health workers must be condemned unreservedly and a clear distinction must be made between community involvement and targeted violence by armed militias. Linking the two is tantamount to stigmatizing the entire community of affected communities, portraying them as deeply violent communities, and blaming the health workers who are the first victims of this targeted violence.

FIGURES OF THE RESPONSE

122,695 vaccinated persons

• 827 people vaccinated on 22/05/2019.

• Of those vaccinated, 33,718 are high-risk contacts (CHR), 60,094 are contacts of contacts (CC), and 28,883 are first-line providers (PPL).

• Persons vaccinated by health zone: 32,281 in Katwa, 24,944 in Beni, 15,549 in Butembo, 9,596 in Mabalako, 6,033 in Mandima, 4,379 in Kalunguta, 3,070 in Goma, 3,048 in Komanda, 2,569 in Oicha, 1,998 in Lubero, 1,985 in Masereka , 1,980 to Kayna, 1,935 to Vuhovi, 1,817 to Kyondo, 1,647 to Musienene, 1,587 to Karisimbi, 1,487 to Bunia, 1,040 to Biena, 1,012 to Mutwanga, 690 to Rutshuru, 557 to Rwampara (Ituri), 527 to Nyankunde, 496 to Mangurujipa, 494 to Alimbongo, 420 to Mambasa, 355 to Tchomia, 342 to Kirotshe, 333 to Lolwa, 250 to Mweso, 245 to Kibirizi, 161 to Nyiragongo, 97 to Watsa (Haut-Uélé) and 13 to Kisangani.

• The only vaccine to be used in this outbreak is the rVSV-ZEBOV vaccine, manufactured by the pharmaceutical group Merck, following approval by the Ethics Committee in its decision of 19 May 2018.

The second-largest Ebola outbreak ever continues to spread, and health officials now say it’s likely to reach the populous city of Goma. Once there, the risk of it spreading beyond the Democratic Republic of Congo to Rwanda, South Sudan, or Uganda increases.

Only a fraction of the health centres in Goma, the capital of North Kivu province, are prepared for a large-scale outbreak. The city, about 300 kilometres from the outbreak’s epicentre, sits at a major trade and migration crossroads and borders Rwanda, where Kigali’s international airport is only 160 kilometres away.

“I wouldn’t say (the spread to Goma) is inevitable, but it’s highly probable,” said Ray Arthur, director of the Global Disease Detection Operations Center at the US Centers for Disease Control and Prevention.

In the past three weeks, the number of areas with reported infections has increased from 21 to 22, with the newest affected area lying between Butembo – a city and trading hub near the epicentre – and Goma, said Arthur. Health zones where transmissions had previously stopped are now seeing new cases again.

If the disease reaches Goma, it will have far-reaching regional implications.

“There would be a whole set of political factors, a huge impact on the economy, and a huge social impact,” said Tariq Riebl, emergency response director for the International Rescue Committee, adding that there would be a domino effect regionally.

While cases in densely populated and well-connected Rwanda would drive up the risk of wider regional spread, South Sudan and Uganda both suffer from an acute lack of trained healthcare workers. The security situation in South Sudan, where sporadic clashes continue, would pose a major challenge, while none of the three neighbouring countries have enough equipped clinics to deal with a large-scale outbreak.

“The longer transmission goes on, the more likely it will get to one of those countries,” Arthur said.

If the WHO declares the outbreak a Public Health Emergency of International Concern, or PHEIC, that would likely lead to travel and trade restrictions – measures that could complicate humanitarian operations if border crossings are closed or suspended.

The WHO decided – for a second time – on 12 April not to declare the Ebola situation in Congo a PHEIC, but is under increasing pressure to do so from some public health experts. One concern if it does is that resulting border closures might increase the risk of transnational spread due to more people travelling illegally through porous borders.

With wider spread now looking likely, more staff from the US Centers for Disease Control and Prevention, Médecins Sans Frontières, UNICEF, and the World Health Organisation – as well as from other groups and NGOs – have been deployed to Goma.

There is currently no dedicated Ebola treatment centre in Goma, so isolating patients may be difficult. Hundreds of small clinics are scattered around the city across a large area, which would make it harder to monitor people if they became sick. There is also a shortage of trained nurses.

After no reported human cases of highly pathogenic avian influenza (HPAI) H7N9 for over a year, a case with severe disease occurred in late March 2019. Among HPAI H7N9 viral sequences, those recovered from the case and from environmental samples of a poultry slaughtering stall near their home formed a distinct clade from 2017 viral sequences. Several mutations possibly associated to antigenic drift occurred in the haemagglutinin gene, potentially warranting update of H7N9 vaccine strains.

Ten former Ontario health ministers from across the political spectrum are taking the rare step of sending a joint letter to the government, imploring it to reverse millions of dollars in public health cuts they say put the province "at risk."

The letter is being sent to Health Minister Christine Elliott on Thursday morning, and is signed by:

• Six former Liberal ministers: Dr. Helena Jaczek, Dr. Eric Hoskins, who served in the Kathleen Wynne government, former deputy premier Deb Matthews, and David Caplan, Elinor Caplan and George Smitherman.

"Traditionally, Ministers of Health have avoided commenting on the policies of their successors," it reads. "Health has been seen as a non-partisan issue — something we all support. This attack on public health has prompted us to break our silence."

The group is calling for a restoration of public health funding to keep water clean, prevent infectious disease, give vaccinations and provide school breakfast programs to children in need.

Concern mounts

Premier Doug Ford's government recently notified municipal public health units in phone calls that it will reduce its cost-sharing levels from 100 per cent or 75 per cent in some cases, to 60 to 70 per cent for some municipalities, and 50 per cent for Toronto. It says the cuts will save Ontario $200 million per year by 2021-2022.

The plans also include cutting the number of public health units in Ontario from 35 to 10.

"If the government wants to end hallway medicine, as you have pledged, one of the best ways to do that is to actually invest more, not less, in public health. We need only look back to the SARS epidemic to realize the devastating impact of failing to invest in public health," the letter says.

"Funding must be restored."

For Toronto, the cuts amount to $1 billion over the next decade, according to city board of health chair Joe Cressy, and mean an immediate $86-million hole in its latest budget. Mayor John Tory called the change a "targeted attack."

With the Ebola epidemic in the Democratic Republic of the Congo now in its tenth month and the number of new cases increasing in recent weeks, the United Nations announced today measures to strengthen its response and end the outbreak.

The Ebola epidemic has claimed more than 1,200 lives and the risk of spread to other provinces in the eastern Congo as well as neighbouring countries remains very high. A third of those who have fallen ill are children, which is a higher proportion than in previous outbreaks.

Under the leadership of the Government and Congolese communities, with support from the UN and non-governmental organizations (NGOs), the response has contained Ebola in parts of Ituri and North Kivu provinces. But ongoing insecurity and community mistrust in the response continue to hamper access to communities. This is hindering efforts by WHO and the Ministry of Health to detect sick people and ensure access to treatment and vaccination, ultimately leading to more intense Ebola transmission.

In view of the increasingly complex environment, the UN in partnership with the Government and all partners is now strengthening its political engagement and operational support to negotiate access to communities; increasing support for humanitarian coordination; and bolstering preparedness and readiness planning for Goma and surrounding countries. WHO is adapting public health strategies to identify and treat people as quickly as possible; expanding vaccination to reach and protect more people; and redoubling work to end transmission in health facilities.

The UN Secretary-General has established a strengthened coordination and support mechanism in the epicenter of the outbreak, Butembo.

MONUSCO Deputy UN Special Representative of the Secretary-General (DSRSG) David Gressly has been appointed UN Emergency Ebola Response Coordinator (EERC) in the Ebola affected areas of the DRC. Mr. Gressly, who brings a wealth of humanitarian leadership and political and security experience to the role, will report to the SRSG, Leila Zerrougui. He will oversee the coordination of international support for the Ebola response and work to ensure that an enabling environment—particularly security and political—is in place to allow the Ebola response to be even more effective.

Mr. Gressly will work closely with WHO, which will continue to lead all health operations and technical support activities to the Government response to the epidemic. Dr. Ibrahima Socé Fall, Assistant Director-General, Emergency Response, who has been in Butembo since end-March, is leading the WHO response in DRC. WHO will also continue to coordinate public health interventions that are being implemented by other UN partners.